About your lifestyle...
* an answer is required for each question
Are you currently pregnant?
Not Applicable
Yes
No
How many servings of fruit and vegetables do you eat per day?
1 serving = about the size of a tennis ball. Example: 1/2 cup fruit and vegetables
None
1-4
At least 5
How many servings of whole grain do you eat per day?
1 serving = about the size of a tennis ball. Example: 1 slice of bread, 1/2 cup pasta
None
1 or 2
3 or more
How many servings of dairy (milk, cheese, etc.) do you consume per day?
1 serving = One, 8-ounce glass of milk, 1 ounce of cheese is about the size of your thumb
None
1 or 2
3 or more
Do you eat green leafy vegetables (kale, spinach, lettuce, etc
) on most days?
Yes
No
How many servings of fish/seafood do you eat per week?
None
1
2 or more
How many times per day do you eat butter, lard, red meat, cheese, whole milk?
None
1
2 or more
Do you eat stick margarine, vegetable shortening, store bought baked goods (cookies, cakes, pies), or deep fried fast foods on most days?
Never
Less than 3 days per week
4 or more days per week
Do you eat oil based salad dressing or use liquid vegetable oil for cooking on most days?
Yes
No
How many servings of refined starch (white bread, white rice, white pasta, potatoes, low fiber cereal like puffed rice or corn flakes) do you eat per day?
None
1
2
3 or more
What is your normal daily consumption of alcohol?
None
1
2
3
4 or more
Do you utilize any street drugs, or prescription drugs not prescribed specifically for you?
Yes
No
Do you use any prescription drugs over the prescribed dosage for you?
Yes
No
Do you smoke?
Yes
No
Used to, but I have quit
Are you routinely or frequently exposed to other peoples smoke from cigarettes or cigars?
Yes
No
Do you use chewing tobacco?
Yes
No
Used to, but I have quit
How many days per week do you walk at least 30 minutes (or do at least 30 minutes of cardiovascular exercise)?
None
1-3
4-6
7
How many hours per week do you engage in moderate physical activity? (walking, biking, etc.)
None
30 minutes
1 hour
1.5 hours
2 hours
2.5 hours
> 3 hours
How many hours per week do you engage in vigorous physical activity? (jogging, swimming)
None
30 minutes
1 hour
1.5 hours
2 hours
2.5 hours
> 3 hours
How many days per week do you engage in moderate to high intensity muscle strengthening / stretching?
None
1 day
2 days
3 days or more
Have you recently been experiencing any of the following (check all that apply)?
Feelings of sadness, anxiety or hopelessness every day for 2 or more weeks
Lack of interest or pleasure in usual activities, hobbies, or pastimes
A sudden increase or decrease in appetite
Trouble sleeping for 2 or more weeks
Excessive sleepiness
Thoughts of death or suicide
Low energy every day for 2 or more weeks
Restlessness
Irritability
Feelings of worthlessness
Change in work performance
None of the above
Does your spouse or significant other (check all that apply):
Hurt you physically when he/she gets angry
Prevent you from seeing your friends or family
Threaten you or yell at you
Make you feels worthless or powerless
Intimidate, berate, or harass you verbally
None of the above
Are you the primary caregiver for a family member, friend, or do you provide care for someone as your occupation?
Yes
No
I used to be
What is your blood pressure?
Unknown
Systolic (top number)
<90
90 - 135
135 - 150
> 150
Diastolic (bottom number)
<50
50 - 90
> 90
What is your total cholesterol?
Over 240
200 to 239
Less than 200
Unknown
What is your HDL?
Over 35
29 to 35
Less than 29
Unknown
What is your LDL?
Over 130
Under 130
Unknown
What is your fasting blood sugar?
Over 250
126 - 250
100 - 125
70 - 100
Under 70
Unknown
Do you perform breast self-examination?
Not applicable
Yes, at least monthly
Yes, but not on a regular schedule or only occasionally
No
Do you perform testicular self exam?
Not applicable
Yes, at least monthly
Yes, but not on a regular schedule or only occasionally
No
Have you recently noticed any of the following (check all that apply):
A lump or thickening in the breast/chest or armpit
Any flattening or indentation of the breast/chest skin
Any puckering, pitting or dimpling of the breast/chest skin
Clear or bloody nipple discharge
A nipple that suddenly becomes retracted or drawn inward
Redness of the breast/chest skin
None of the above
When was your last mammogram?
Not applicable
I am over 50, or have found a lump on breast self exam, or have a family history of breast cancer, but have never had a mammogram
I am under 50, have never found a lump on breast self exam, and have no family history of breast cancer so have never had a mammogram
My last mammogram was within the past 1 year
My last mammogram was within the past 2 years
My last mammogram was more than 2 years ago
When was your last Pap test?
Not applicable
Prior to my hysterectomy
More than 3 years ago
Between 1 and 3 years ago
Less than 1 year ago
I have never had a Pap Test
When was your last prostate exam?
Not applicable
Within the past year
I am under 50 and have had an exam within the past 5 years
I am over 50 and have had an exam between 1 and 5 years ago
Over 5 years ago
I have never had a prostate exam
When was your last colorectal cancer screening?
I am under 50 years old
I am over 50 years old and have had a sigmoidoscopy within the last 7 years
I am over 50 years old and had a sigmoidoscopy more than 7 years ago
I am over 50 years old and have never had a sigmoidoscopy
When was your last dental exam?
Never
More than 5 years ago
Between 1 and 5 years ago
In the past 1 year
When was your last flu shot?
I never get flu shots because I am allergic
My doctor has advised me to not take flu shots
I am under 50 and do not routinely get flu shots
I am over 50 and do not routinely get flu shots
I get a flu shot annually
Have you had any recent (within the last 6 months) changes in bladder or bowel habits?
No
Yes, but my doctor said it was normal
Yes, and I have not yet discussed it with a doctor
Have you noticed a lump or thickening in the breast or elsewhere?
No
Yes, but my doctor said it was normal
Yes, and I have not yet discussed it with a doctor
Have you had any unusual bleeding or discharge?
No
Yes, but my doctor said it was normal
Yes, and I have not yet discussed it with a doctor
Do you have any slow or non-healing sores?
No
Yes, but my doctor said it was normal
Yes, and I have not yet discussed it with a doctor
Have you had any obvious changes to size, shape, or color of a wart or mole?
No
Yes, but my doctor said it was normal
Yes, and I have not yet discussed it with a doctor
Have you recently had a nagging cough or hoarseness?
No
Yes, but my doctor said it was normal
Yes, and I have not yet discussed it with a doctor
If given the opportunity to work with a nurse to alter your risk creating lifestyle, behavior, or diet practices I would...
Be an active participant in anything the RN had to offer as long as it was inexpensive
Be an active participant in anything the RN had to offer as long as it was free
Listen to what the RN has to say then make my own adjustments
Prefer to have information by mail or e-mail only, and not talk with a RN
Not be willing to address these issues further
What would motivate you to make health life syle changes?
Health courses sponsored by DMH
Better variety of healthy foods in Cafe
Discounted gym membership at DMH facilities/YMCA
Other: